Names and birthdates of other children in the home under the age of 18 who will not
be receiving childcare/preschool services

Family Information

Family Size

Total Gross (Monthly) Household Income. Please enter monthly amount from all sources
BEFORE any deductions:

Please check all sources of income that apply:

Adoption Subsidies

Cash Aid TANF

CAN

Child Support

Foster Grants

Inclusion

Military

Pensions

Social Security

Spousal Support Survivor Benefits

Student Financial Aid specifically for living expenses

Unemployment Disability Workers Compensation

I understand that it is my responsibility to notify AHC Childrens Lab School of any
changes to the information on this application. Failure to report changes may be cause
for removal of this application from the eligibility list. I agree that the information
provided above is accurate and may be shared with other agencies in helping me receive
childcare services.